A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Perform passive range of motion on each extremity.
Record the client's intake and output.
Suction saliva from the client's mouth.
Monitor the client's electrolyte levels.
The Correct Answer is C
The highest priority nursing intervention for a client who is unconscious following a stroke is to suction saliva from the client's mouth. This can help prevent aspiration and maintain a patent airway, which is essential for the client's survival.
Performing passive range of motion on each extremity, recording the client's intake and output, and monitoring the client's electrolyte levels are also important nursing interventions for this client. However, these interventions are not as high of a priority as maintaining a patent airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
If a client returns to the surgical unit from the PACU in skeletal traction and the weights rest against the foot of the bed, the nurse should take action to correct this problem with the traction setup. The weights should be hanging freely and not touching any part of the bed or floor. This ensures that the traction is providing the appropriate amount of force to the affected limb.
The other options listed are not problems with the traction setup. The ropes should be in the center of the wheel grooves, the weights should be equal on each side, and the ropes should attach securely to the pin.
Correct Answer is A
Explanation
a.A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.
b.A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.
c.A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.
d.A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.
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